Surgeries not covered by medical insurance

When it comes to surgery, your medical insurance or healthcare plan will only cover certain procedures. What can you do to cover those extra surgical needs that fall outside of the scope?

If you don’t have a specific healthcare surgery coverage plan, you may find yourself paying out of your own pocket. Most plans will cover you for a large amount of procedures. There are however several invasive, preventative or cosmetic surgeries that are not covered.

While each healthcare provider or insurance plan may differ on the details, here’s what is generally excluded by standard medical aids:

1. Cosmetic

Cosmetic procedures are not covered. These include any aesthetic procedures that a patient will elect to undergo and are not medically necessary. They include face lifts, breast augmentation, rhinoplasty and more. Breast reduction is also currently classified as cosmetic, however there are current movements to amend this within the South African medical landscape.

2. Gastric bypass

Gastric bypass surgery or a “lap band” is generally not covered by a standard medical aid plan. Certain schemes are adding this procedure to their coverage list. In these cases, cover may include partial or full cover. Co-payments are usually required.

3. Dental surgeries

Dental surgeries that a patient chooses to undergo are more than likely not covered to any degree. These include any dental procedures classified as a lifestyle improvement versus medically required, such as implants and dentures.

4. Sex reassignment

Sex reassignment surgery is also currently classified as not medically necessary and is not covered by medical aid plans.

It’s important to confirm with your current medical healthcare insurance provider what preventative or invasive surgeries are or are not included, as different plans have different classifications for these categories.

Most medical plans will cover you for a standard list of prescribed minimum benefits or PMBs. These are regulated by the Medical Schemes Act and include coverage for over fifteen categories such as chronic disease benefits, emergency medical treatments and a set list of 270 other medical conditions. Read our article to learn the difference between health insurance and medical aid.

It’s clear that there are plenty of gaps when it comes to surgical healthcare coverage on your standard medical insurance plan. Some additional gap cover options will provide extra coverage for certain procedures not handled by your main scheme.

At Bloom, we can offer extra assistance with our Major Medical Event benefits. This additional coverage can be taken in conjunction with our Health4Me day-to-day benefits. It offers benefits such as hospital cash back and accident and emergency coverage, that will help contribute to your medical needs.

Learn more about our Major Medical Events benefits today. 



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Momentum Health4Me is not a medical scheme product, and is not a substitute for medical scheme membership. The information provided on this website does not constitute advice in terms of the Financial Advisory and Intermediary Services Act. Momentum is a division of Momentum Metropolitan Life Limited, an authorised financial services provider (FSP 6406) and a wholly owned subsidiary of Momentum Metropolitan Holdings Limited.

Bloom Gap Cover is not a medical Scheme. Products that are offered are not the same as that of a medical scheme.

© Bloom Financial Services 2023. Bloom Financial Services (Pty) Ltd is an authorised financial services provider (FSP 50140). Bloom Gap is underwritten by Infiniti Insurance Limited a licensed non-life insurer and an authorised financial services provider (FSP No.35914)

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